Report of the Committee on Dermatology Services /[chairman: Cillian Twomey]

Transcription

1 Report of the Committee on Dermatology Services /[chairman: Cillian Twomey] Item Type Report Authors Twomey, Cillian Rights Comhairle na nospideal Download date 04/10/ :37:39 Link to Item Find this and similar works at -

2 Comhairle na nospidéal Report of the Committee on Dermatology Services November 2003 Comhairle na nospidéal Corrigan House, Fenian Street, Dublin 2. TEL: FAX: info@comh-n-osp.ie WEBSITE: Chairman: Dr. Cillian Twomey Vice-Chairman: Dr. Donal Ormonde Chief Officer: Mr. Tommie Martin

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4 CONTENTS Page EXECUTIVE SUMMARY 1 Section 1 INTRODUCTION Context The Consultation Process 2 2 WHAT IS DERMATOLOGY? Definition and Scope of Dermatology The Work of a Consultant Dermatologist Training in Ireland Dermatology Training outside Ireland Qualifications specified by Comhairle na nospidéal for posts of Consultant Dermatologist 7 3 EXISTING DERMATOLOGY SERVICES Previous Comhairle na nospidéal Report on Dermatology Services (July 1988) National Distribution of Dermatology Services Eastern Regional Health Authority East Coast Area Health Board Northern Area Health Board South Western Area Health Board Midland Health Board Mid-Western Health Board North Eastern Health Board North Western Health Board South Eastern Health Board Southern Health Board Western Health Board Other Dermatology Services 14 4 MAJOR ISSUES CONSIDERED BY THE COMMITTEE International Consultant Staffing Levels Hume Street Hospital Dermatology Services for Children Dermatosurgery Dermatopathology Waiting Lists 17 5 PRINCIPLES FOR FUTURE DEVELOPMENT Equitable and Patient-Centred Service No Consultant Dermatologist Working in Isolation Regional Self-Sufficiency Dermatology Teaching and Research Telemedicine Collaboration between Primary and Secondary Care 21 i

5 6 RECOMMENDATIONS Equity Regional Self-sufficiency Models of Service Provision Future Consultant Staffing Specialisation Academic Posts Nurse-led Dermatology Clinics 26 7 CONCLUDING REMARKS 27 8 REFERENCES 28 9 APPENDICES 30 Appendix A List of questions posed to all Health Boards and relevant Public Voluntary Hospitals 30 Appendix B Submissions received by Committee and meetings held 31 Appendix C Information supplied by hospitals to Committee 32 Appendix D Review of the Comhairle na nospidéal Report on Dermatology Services (July 1988) 34 Appendix E Summary of recommendations for Northern Area Health Board 36 ii

6 EXECUTIVE SUMMARY The Comhairle na nospidéal Committee on Dermatology Services commenced its review of dermatology services in February At that time, dermatology services were acknowledged to be underdeveloped nationally and two health boards the Midland Health Board and North Western Health Board were without a locally based permanent consultant dermatologist. The areas requiring development were clear from the outset. There are currently 19 posts of consultant dermatologist approved by Comhairle na nospidéal, representing a ratio of one consultant dermatologist per 206,000 population. The work of the committee initially focused on reviewing the implementation of the recommendations of the previous Comhairle report on dermatology services, which was published in In addition, all health boards and relevant voluntary hospitals were asked to make submissions to the committee. Over the course of a year the committee met with the Irish Association of Dermatologists, comprising the consultant dermatologists practising in the public hospitals in Ireland; managerial representatives from all of the health boards and relevant voluntary hospitals; carried out site visits to the Mater Misercordiae and Beaumont Hospitals; and visited a recommended centre of excellence for dermatology at Ninewells Hospital, Dundee. The committee also consulted literature relating to dermatology service provision in the UK, Europe, North America and Australia. The main principles identified by the committee for the future development of dermatology services are ü An equitable and patient-centred service ü No consultant dermatologist working in isolation ü Regional self-sufficiency ü Collaboration between primary and secondary care The key recommendations are as follows, ü A ratio of one consultant dermatologist per 100,000 population ü A doubling of the number of consultant dermatologist posts, from 19 to 38 ü The immediate appointment of consultant dermatologists to the Midland Health Board and the North Western Health Board ü The priority appointment of 12 additional consultant dermatologists throughout the country and the subsequent appointment of an additional seven consultant dermatologists ü The development of a Moh s micrographic surgery service ü The transfer of Hume Street Hospital to the St Vincent s University Hospital campus ü The development of academic posts in dermatology ü The development of the role of specialist dermatology nurses. 1

7 1 INTRODUCTION 1.1 CONTEXT Following the receipt of correspondence from the Irish Association of Dermatologists, it was decided, at the meeting of Comhairle na nospidéal on 21st November 2001, to establish a committee to meet with representatives of the Association The following members were appointed to serve on the Dermatology Committee: Dr C Twomey (Chairman) Mr D Doherty Mr C O Leary Mr T Martin Consultant Physician in Geriatric Medicine, Cork University Hospital; Director, The Health Boards Executive; Consultant in Emergency Medicine, Mid-Western Regional Hospital, Limerick; Chief Officer, Comhairle na nospidéal Ms C Mellett, Executive Officer, was appointed as Secretary to the committee and she undertook the research for, and drafting of, this report The first meeting of the committee took place on 19th February The terms of reference of the Dermatology Committee were as follows: To examine the existing arrangements for the provision of consultant dermatology services nationally and following consultation with the interested parties, to make recommendations to Comhairle na nospidéal on the future organisation and development of dermatology services. The review will focus on the 1988 Comhairle Report on Dermatology Services. It will examine the extent of the implementation of the recommendations of the 1988 report It was apparent to the committee that dermatology services in Ireland were concentrated mainly in the Dublin region, representing a significant inequity in service provision. Two health boards- the Midland and North West- had no consultant dermatologists, while two further health boards- the Mid-Western and South Eastern - were operating dermatology services with one consultant dermatologist. The areas requiring development were clear to the committee from the outset. 1.2 THE CONSULTATION PROCESS Requests were made to each health board and relevant public voluntary hospital to make submissions to the dermatology committee. Each was asked to comment on:- ü the level of implementation of the Comhairle na nospidéal Report on Dermatology Services (1988) and ü the recommendations of the Irish Association of Dermatologists on the future development of dermatology services in Ireland. Each was also asked for information relating to workload, facilities etc. The list of questions posed is given at Appendix A. The submissions received are listed at Appendix B and some details of the responses are included at Appendix C The committee met with representatives of the Irish Association of Dermatologists (IAD) on 5th June 2002 and with management representatives of each health board and relevant voluntary hospital on 24th September Representatives of the committee visited the dermatology facilities at the Mater Misercordiae Hospital in November 2002 and at Beaumont Hospital in March In February 2003, representatives of the committee travelled to Ninewells Hospital, Dundee, Scotland, to view 2

8 the dedicated dermatology facilities and consulted with key personnel there. This hospital had been recommended to the committee by the Irish Association of Dermatologists as a centre of excellence. The visit provided the committee with valuable information and advice vis-à-vis the future development of a high quality dermatology service. The committee wishes to extend its gratitude to all those involved in the consultation process, in the compilation of submissions, and all those who provided additional information and assistance to the committee. The committee would like to pay particular thanks to the members of the IAD for their precise and informative presentations and their uniform approach to the national development of dermatology services in the Republic of Ireland, which was most encouraging to the committee. Special mention must be given to Dr Paul Collins, Dr John Bourke and Dr Rosemarie Watson who provided particular assistance, support and advice to the committee. Note: This report is written and its recommendations are made in the context of the existing medical staffing system, hospital network and health board configuration. The committee is aware of the recommendations of the recently published report of the National Task Force on Medical Staffing (Hanly Report) and impending European Working Time Directive. The Committee believes that this Dermatology report will guide and further inform the implementation of the Report and the related implementation of the EWT Directive in Ireland. 3

9 2 WHAT IS DERMATOLOGY? 2.1 DEFINITION AND SCOPE OF DERMATOLOGY Dermatology is the medical specialty caring for illnesses relating to the skin, hair and nails. Dermatology is also concerned with many diseases affecting the genitalia and the inside of the mouth. Dermatologists treat patients of all ages. Apart from a small number of potentially fatal conditions, dermatology is not a life or death specialty, and as a consequence has seldom been a top priority for development at hospital management or medical board level, or nationally. Other, more high profile specialties tend to attract more public attention and media coverage. The fact is that skin disease is very common - between one third and one quarter of the population has a dermatological condition at any one time and most skin diseases are characteristically chronic. These conditions range from the more common acne, dermatitis and skin infections to Epidermolysis bullosa and skin cancer. Dermatological conditions result in major quality of life issues, with some conditions being physically disabling, disfiguring, painful and intensely irritating, resulting in loss of sleep, disruption of family life, teasing and bullying in schools, difficulty in obtaining work and severe problems in forming social relationships. The visual nature of skin disease is thought to render patients more susceptible to disturbed body image, lack of confidence and even depression. 1,2,3 2.2 THE WORK OF A CONSULTANT DERMATOLOGIST Dermatology is, predominantly, an out patient specialty, with only a small proportion of patients requiring admission to hospital. A significant amount of the consultant s time (up to three sessions per week) can be taken up with consults for inpatients on medical and surgical wards under the care of other consultants Common Skin Conditions Five groups of skin diseases make up 90% of the workload of a consultant dermatologist. These are Dermatitis, Psoriasis, Acne, Skin Cancer and Skin Infections. Dermatitis Atopic Eczema/Dermatitis affects up to 15-20% of children in Western Europe and a two to three fold increase in prevalence has been detected over the past 30 years. 1,4 Psoriasis Psoriasis affects 2% of the population and has an important genetic factor. 4 For the majority of sufferers, it is a chronic disease. 1 Many patients requiring phototherapy must attend for treatment 3 times per week and more severe cases need treatments that require monthly monitoring. Acne Acne affects 85% of the year old population and can lead to social embarrassment and, in some cases, psychological damage. The condition is severe in 2% of the population. Skin cancer Skin cancer (melanoma and non-melanoma) represents the most common form of cancer and its incidence is increasing. On average every year in Ireland, approximately 400 cases of melanoma are detected and there are, on average, 60 deaths attributable annually to melanoma. Around 5,000 cases of non-melanoma are detected each year and there are approximately 30 deaths per year from non-melanoma cancer. 5 The higher risk of skin cancer encountered by renal transplant recipients 6,7 also needs to be taken into account. 4

10 Skin Infections Skin infections include fungal infections, warts, scabies, bacterial infections, impetigo and cellulitis, some of which are relatively common Rarer Skin Conditions Epidermolysis Bullosa (EB) Epidermolysis Bullosa (EB) is a group of inherited conditions, typically manifested in infancy or childhood, in which there is fragility of the skin and mucous membranes. Any friction, rubbing or trauma to skin and/or mucous membranes causes blisters and skin to come off. It can range from a relatively mild condition to a severely disabling, and sometimes fatal, disease. There are an estimated 200 people with EB in Ireland. 8 As yet, a cure has not been found for EB, nor has a treatment to completely control any form of EB. Many forms of EB begin to lessen to some degree as the child gets older. 9 Currently, a consultant dermatologist based at Crumlin and St James s Hospitals has expertise in this condition and these hospitals have become referral centres for the rest of the country. 2.3 TRAINING IN IRELAND UNDERGRADUATE TRAINING IN DERMATOLOGY IN IRELAND Dermatology does not currently form part of the core training for medical students. Exposure to training in dermatology should commence at the undergraduate level of medical training and dermatology should form a core part of undergraduate medical training in Ireland. Currently undergraduate training in dermatology is determined by the location of consultant dermatologists and is restricted by the limited number of consultant dermatologists. The committee acknowledges that the current low level of undergraduate training in dermatology may be due, in part, to the inadequate number of consultant dermatologists in the state. The committee hopes that with the implementation of its recommendations, dermatology training of medical students will be significantly enhanced and will form part of the core training curriculum at this level. In Scotland, undergraduate teaching in dermatology continues to evolve. There, it is proposed that the undergraduate curriculum will involve exposure to an increasing level of dermatology each year. For example, in first year, there would be three dermatology lectures, increasing to a one-week attachment to a consultant dermatologist in third year and a subsequent two-week attachment. With the implementation of the committee s recommendations and the appointment of additional consultants in Ireland, the scope for similar development of undergraduate training in dermatology will exist Postgraduate Training in Medicine in Ireland Following completion of the pre-registration intern year, medical graduates may enter post-graduate training schemes in their chosen specialty. Initial Specialist Training (2-3 years), previously known as general professional training is followed, depending on the specialty, by a duration ranging from 4 to 6 years of Higher Specialist Training (HST). The responsibility for the coordination of HST schemes in Ireland lies with the relevant training body for each specialty group. The Medical Council recognises twelve such training bodies. The Irish Committee on Higher Medical Training (ICHMT) of the Royal College of Physicians of Ireland (RCPI) is responsible for developing and coordinating the training programmes in medicine in Ireland. Centres for specialist registrar training are inspected by a Specialist Training Committee (STC) consisting of the National Specialty Director of the relevant specialty, an ICHMT representative, and the Dean or Associate Dean of the ICHMT. The team meet with the clinical and administrative staff of the hospital/training institution as well as the trainee(s). Following educational approval of centres for SpR training by the STC of the ICHMT, application to Comhairle na nospidéal may be made for the formal approval of SpR posts. Following successful completion of the HST, the doctor is awarded a Certificate of Satisfactory Completion of Specialist Training (CSCST) and may apply to the Medical Council for inclusion on the Register of Medical Specialists. 5

11 2.3.3 Postgraduate Training in Dermatology in Ireland Applicants to the higher specialist training (HST) scheme in dermatology must have completed a minimum of two years Initial Specialist Training in approved posts and obtained the MRCP(I) or MRCP(UK). The HST scheme in dermatology is of four years duration and has been in operation since 1st July A minimum of one consultant dermatologist at a centre is required for educational approval by the STC. ICHMT guidelines state that each trainee can spend up to two years at any one training institution and a maximum of one year at a one-consultant unit and that a trainee can spend no more than one year training with any one trainer. The training programme allows for up to two years of overseas training (clinical or research). While all training can be completed in Ireland, many trainees choose to spend time training abroad. There are six centres recognised for training in Ireland Beaumont Hospital, the Mater Hospital, St James s Hospital/Crumlin Hospital, St Vincent s Hospital/Hume Street Hospital, the South Infirmary-Victoria Hospital, Cork and Waterford Regional Hospital. Each centre is recognised for one training post and all six SpR posts are approved by Comhairle na nospidéal. Recruitment of trainees takes place once a year and is undertaken by the ICHMT GP training in Dermatology in Ireland The amount of exposure to formal dermatology training for GPs varies. GP trainees are exposed to, and trained in the management of, common dermatological conditions during their GP-based training year. However, dermatology does not form part of the core training for trainee GPs. In some GP training programmes, some trainees get attachments to hospital dermatology outpatient departments during their first or second (hospital based) years of training. A Higher Diploma in Medicine (Dermatology) for General Practitioners, recognised by the Irish College of General Practitioners, is run by University College Dublin at the Mater Hospital. GPs obtain extensive clinical exposure to patients throughout the six-month intensive period of study. Teaching is provided by many of the Consultant Dermatologists in Ireland. The course extends over approximately twenty weekends in Dublin and both written and clinical examinations must be passed. The committee has been informed that the course has been very successful. 10 It is estimated that approximately 10% of the GPs practising in the state have completed the course. The committee has been advised that there is scope for the development of similar courses in other parts of the country. Some Irish GPs undertake a Diploma in Practical Dermatology, run by the University of Wales College of Medicine, Cardiff, by distance learning. This course is also approved by the ICGP for GPs in Ireland. 11 The Irish College of General Practitioners coordinate courses for GPs in minor surgery and cryosurgery, which incorporate some dermatology. A number of these day and weekend courses are run in different parts of the country throughout the year. The courses offer practical experience to GPs, however, no formal certification is issued on completion of the course. The curriculum for Higher Medical Training in Dermatology in Ireland includes a module for the SpR trainees at the primary care level - 10 sessions to be held at an approved Health Centre during the course of the training scheme. In this way, future dermatologists may appreciate the needs and contribution of general practitioners to the provision of dermatology services. 6

12 2.4 DERMATOLOGY TRAINING OUTSIDE IRELAND Dermatology Training in the UK Higher specialist training in dermatology in the UK is similar to that in Ireland. The Higher Medical Training Scheme in Dermatology in the UK is accredited by the Joint Committee on Higher Medical Training of the Royal College of Physicians (London). 12 Applicants to the scheme must first have completed two years of postgraduate training in approved posts and obtained the MRCP(UK) or MRCP(I) or MRCPCH. The duration of higher medical training in dermatology in the UK is four years, leading to the award of CCST Dermatology Training in North America The American Board of Medical Specialties (ABMS) is the umbrella organisation for the 24 approved medical specialty boards in the United States, one of which is the American Board of Dermatology. The postgraduate training scheme in dermatology in the US is accredited by the Accreditation Council for Graduate Medical Education (ACGME). 13,14 The programme is of four years duration, the first of which is a broad-based year of clinical training. This is followed by three years of training in dermatology. Successful completion of the programme leads to eligibility to sit the examination for certification of the American Board of Dermatology, leading to the title of Diplomate of the American Board of Dermatology. The Board also certifies the subspecialties of Dermatopathology, Clinical and Laboratory Dermatological Immunology, and Paediatric Dermatology. In Canada, 15 applicants for higher training in dermatology must possess an MD, which usually follows a BSc degree. Application is then made for a residency place of five years duration in a chosen medical specialty. A residency in dermatology would comprise three years of rotation through various specialties, followed by two years concentrating on dermatology. Upon successful completion of these five years, the resident sits the exams of the Royal College of Physicians and Surgeons of Canada, the accreditation body for all medical specialists in Canada Dermatology Training in Australia In Australia, 16 the higher training scheme in dermatology is accredited by the Australian College of Dermatologists. Upon completion of the initial medical degree (5-7 years), two years are then spent in a public hospital. Application can then be made to the training scheme in dermatology, which is of four years duration. Successful completion of the scheme leads to Fellowship of the Australian College of Dermatologists (FACD). Fellowships in subspecialty areas such as Mohs micrographic surgery, laser therapy, other advanced dermatological and cosmetic procedures, and skin allergy are also undertaken in Australia by dermatologists. 2.5 QUALIFICATIONS SPECIFIED FOR POSTS OF CONSULTANT DERMATOLOGIST The following are the qualifications which are specified by Comhairle na nospidéal for consultant appointments in dermatology: Consultant Dermatologist (a) Full registration in the General Register of Medical Practitioners maintained by the Medical Council in Ireland or entitlement to be so registered and (b) The possession of the MRCPI or a qualification in medicine equivalent thereto and 7

13 (c) (i) Inclusion on the division of dermatology of the Register of Medical Specialists maintained by the Medical Council in Ireland or Comhairle na nospidéal - Report of the Committee on Dermatology Services - November 2003 (ii) Seven years satisfactory postgraduate training and experience in the medical profession including four years in dermatology Consultant Dermatologist with a special interest in paediatric dermatology a, b and c, as specified above, and (d) including one year in paediatric dermatology. 8

14 3 EXISTING DERMATOLOGY SERVICES 3.1 PREVIOUS COMHAIRLE NA NOSPIDÉAL REPORT ON DERMATOLOGY SERVICES (JULY 1988) Table 1 Health Board Area & Population (2002 census) 17 Following an announcement by the Minister for Health on 19th May 1987, a major review of acute hospital services in the country was undertaken by the Department of Health and Comhairle na nospidéal. Subsequently, Comhairle was requested to undertake, inter alia, a review of dermatology services. The report of the Comhairle committee on dermatology services was published in July The concentration of dermatology services in the Dublin region identified in the 1988 report reflects a situation that prevails today. The principles and recommendations of the 1988 report are summarised at Appendix D. The 1988 report was written during a period of considerable economic uncertainty and severe cutbacks in all areas of public spending, including health, when a number of hospitals were closed in The 1988 committee conceded that while single-handed consultant appointments should be avoided if at all possible, it would have been unrealistic, given the economic climate at the time, to expect the appointment of a large number of new consultant dermatologists. It was accepted in 1988 that pending an improvement in the economic situation, initial improvements in dermatology consultant manpower would have to take the form of single-handed consultant posts, if dermatology services in some health boards were to be provided. In view of cutbacks, it was decided to concentrate services in four centres (details are given at Appendix D). Table 1 summarises the consultant staffing at the time of the drafting of the 1988 report, the recommendations of the report in relation to consultant staffing and the current situation. Consultant Posts (Sept 1987) Total posts Recommended Current Consultant Establishment (2003) Implementation (current Consultant Establishment as % of recommendations of report) Current Cons./Population Ratio (2003) EHB / ERHA 1,401, * % 1/140,000 MHB 225, NEHB 344, /172,000 MWHB 339, % 1/340,000 NWHB 221, % 1/222,000 SEHB 423, % 1/424,000 SHB 580, % 1/290,000 WHB 380, % 1/190,000 TOTAL 3,917, % 1/206,000 * The Dublin region was proposed as a dermatological centre to serve a catchment area including the North Eastern Health Board and the Midland Health Board 9

15 The recommendations, in terms of consultant staffing were implemented in the eastern region and the Western Health Board. The recommendation with regard to the North Western Health Board has recently (April 2003) been implemented. However the targets set for the other health board areas have not been realised. The recommendation that outpatient clinics be provided at Navan, Longford, Tullamore, Portlaoise by consultants based in Dublin hospitals has not been implemented. In light of economic circumstances at the time and the subsequent shift in opinion regarding regionalisation, the four regional centres recommended by the committee have not developed as recommended, particularly in terms of providing out-reach services to other general hospitals in their catchment areas. 3.2 NATIONAL DISTRIBUTION OF DERMATOLOGY SERVICES DISTRIBUTION OF CONSULTANT DERMATOLOGY POSTS There are currently 19 Comhairle approved permanent posts of Consultant Dermatologist in Ireland. Figure 1 illustrates the current distribution of consultant dermatology posts in the state. The ERHA, with 35.7% of the total population has 55.5% of all of the Consultant Dermatologist posts in the country. In contrast, the Midland Health Board with 5.7% of the population has no locally based consultant dermatologist. Fig 1. Distribution of Population and Consultant Dermatologist Posts by Health Board Area Percentage % of state population %of total consultant dermatologist establishment 0 ECAHB NAHB SWAHB MHB MWHB NEHB NWHB SEHB SHB WHB Health Board Area All population figures used are those provided in the Census 2002 figures Distribution of NCHD posts in Dermatology There are 24.5 non-consultant hospital doctor posts in dermatology in Ireland. The ratio of consultants to NCHDs in dermatology compares favourably with that of other specialties. The NCHD posts in dermatology are distributed by hospital and grade as follows, 10

16 Hospital SHO Registrar SpR Total Beaumont Drogheda (OLOL) Hume Street Limerick Regional Mater Our Lady s Hospital, Crumlin St James s St Vincent s South Infirmary - Victoria Tallaght UCH Galway Waterford Regional Total Data derived from Survey of NCHD Staffing at 1st October 2002, Postgraduate Medical and Dental Board EASTERN REGIONAL HEALTH AUTHORITY Population: 1,401,441 The dermatology service in the ERHA is provided at nine hospitals, including two children s hospitals and Hume Street Hospital. There are 10 consultants providing the service in these hospitals. While the number of consultants is disproportionately high in the eastern region, it should be remembered that some of these consultants provide specialised services, catering for patients from all over the country and not just the immediate catchment area. More significantly, the limited number of dermatologists in some neighbouring health boards has led to considerable referrals to dermatologists in the Dublin hospitals for routine dermatology diagnoses and treatments. The statutory functions of the ERHA are the planning, commissioning, funding, monitoring and evaluation of all health and personal social services for the people of Dublin, Kildare and Wicklow. The three area health boards within the ERHA - the East Coast Area Health Board (population 333,458), the Northern Area Health Board (population 486,305), and the South Western Area Health Board (581,551) and the voluntary hospitals in the region are responsible for service delivery. The breakdown of sessions at each hospital in the ERHA is given in sections 3.4, 3.5 and 3.6 below. 3.4 EAST COAST AREA HEALTH BOARD Population: ~333,488 The consultant staffing at the hospitals in the east coast area is outlined (as consultant sessions per week per consultant post at each hospital) as follows: St Vincent s/st Michael s Hume Street Sessions per week Post Post Total

17 3.5 NORTHERN AREA HEALTH BOARD Population: ~486,349 The consultant staffing, in the form of consultant sessions per week per consultant, at the hospitals in the northern area health board region is as follows: Beaumont Mater Temple St. JCM Blanchardstown Other Sessions per week Sessions per week Post (NEHB) Post Service to NEHB Post 3 (unprocessed) Post 4* 3 6 2(MHB) Total *Consultant Dermatologist with a special interest in paediatric dermatology 3.6 SOUTH WESTERN AREA HEALTH BOARD Population: ~581,603 The consultant staffing, set out as consultant sessions per week, at the hospitals in the south western area health board region is outlined as follows: Crumlin St James s Tallaght Sessions per week Post 1 11 Post Post Post 4* 8 3 Total * Consultant Dermatologist with a special interest in paediatric dermatology 3.7 MIDLAND HEALTH BOARD AREA Population: 225,363 There is currently no permanent consultant dermatologist based in the Midland Health Board. A Consultant Dermatologist, based at Temple Street and the Mater Hospitals provides two sessions per week at the Midland Regional Hospital at Mullingar. 3.8 MID WESTERN HEALTH BOARD AREA Population: 339,591 There is one Consultant Dermatologist in the Mid-Western Health Board, with 10 sessions at the Mid-Western Regional Hospital, Limerick and one session at Cork University Hospital. This consultant has no formal commitment to St John s Hospital in Limerick but attends as requested. 3.9 NORTH EASTERN HEALTH BOARD AREA Population: 344,965 There are two Consultant Dermatologist posts approved in the North Eastern Health Board. The sessional commitments of the posts (consultant sessions per week) are distributed as follows: 12

18 Drogheda Dundalk Monaghan Cavan Other Sessions per week Post (Beaumont) Post 2 (V.A.) Total (V.A. vacant approved post) For a number of years, two Dublin based consultant posts have had formal sessional commitments to the NEHB, amounting to one session per month at the hospitals in Drogheda, Dundalk and Cavan NORTH WESTERN HEALTH BOARD AREA Population: 221,574 Until very recently (April 2003) there was no permanent, locally-based, post of consultant dermatologist in the NWHB. A visiting consultant from Altnagelvin Hospital NHS Trust provides a weekly session in Letterkenny General Hospital and a Comhairle approved temporary consultant dermatologist has provided services at Sligo General Hospital. In April 2003, Comhairle na nospidéal approved the appointment of a permanent Consultant Dermatologist to the NWHB, with eight sessions per week at Sligo General Hospital and three sessions per week to Letterkenny General Hospital SOUTH EASTERN HEALTH BOARD AREA Population: 423,616 There is one Consultant Dermatologist in the South Eastern Health Board, based at Waterford Regional Hospital. All in-patient dermatology work is carried out at Waterford Regional. Two out patient clinics per month are held at Wexford, Kilkenny and Clonmel respectively SOUTHERN HEALTH BOARD AREA Population: 580,356 The dermatology unit for the Southern Health Board population is located at the South Infirmary-Victoria Hospital, Cork and is staffed by two consultants. The breakdown of the posts (average sessions/week) is as follows; South CUH Mercy Other Infirmary- Victoria Sessions per week Post Post (Out patient clinics & in patient consults) (Out patient clinics in Tralee) Total WESTERN HEALTH BOARD AREA Population: 380,297 There are two Consultant Dermatologists, both based at University College Hospital, Galway. In addition, out-patient clinics are held at a number of centres in the region, including Castlebar, Ballina, Roscommon and Portiuncula. 13

19 3.14 OTHER DERMATOLOGY SERVICES DERMATOLOGISTS IN FULL-TIME PRIVATE PRACTICE There are at least nine dermatologists working exclusively in private practice in Ireland while there are 19 permanent consultant dermatologist posts employed in the public sector many of whom also work in the private sector. This situation whereby one third of a specialty work solely in private practice is in sharp contrast to the distribution found in other specialties, which may reflect the failure to properly develop publicly funded dermatology services THE ROLE OF GENERAL PRACTITIONERS Dermatology is an area where significant cooperation should exist between the primary and secondary care levels to ensure a seamless progression of treatment for the patient. Skin diseases account for approximately 15% of the workload of a general practitioner and 6% of GP prescriptions relate to skin disease. 1,2 Approximately 76% of dermatology consultations in primary care arise from a small number of conditions, including eczema, psoriasis, acne and leg ulcers. UK studies 1,2 have estimated that only 5% of patients presenting to GPs for dermatological treatment are referred to a Consultant Dermatologist. However, the vast majority of patients referred to secondary dermatological care suffer severe or chronic conditions and there is clearly an unmet need at this level. 1, DERMATOLOGY IN MATERNITY HOSPITALS The committee has been advised that there are some skin conditions peculiar to pregnant women that may necessitate the opinion of a Consultant Dermatologist. It is important that pregnant women and neonates with atypical skin rashes can access the opinion of a Consultant Dermatologist with an interest in these areas. 14

20 4 MAJOR ISSUES CONSIDERED BY THE COMMITTEE 4.1 INTERNATIONAL CONSULTANT STAFFING LEVELS The Irish Association of Dermatologists recommends a consultant/population ratio of 1/85,000. The existing ratios of specialists in dermatology to population in a number of countries are given below: Country Population Number of Dermatologist / (million) Dermatologists Population* (posts) Ireland /206,000 Northern Ireland /125,000 Scotland /108,000 England & Wales /163,000 Canada /77,000 Denmark /35,000 USA ,900 1/29,000 Sweden /26,000 Source of population figures: World Population Profile US Bureau of the Census; 19 Local census figures * It should be noted that different hospital and medical staffing systems and hierarchies exist in different countries as regards grades of doctors so that direct comparison is difficult except with Northern Ireland, Scotland and England & Wales. For example, specialists, as distinct from consultants, are employed in most EU countries other than Ireland and the UK. The proportion of NCHDs to specialists/consultants employed in most EU countries and North America is also much lower than that in Ireland or the UK. 4.2 HUME STREET HOSPITAL The 1988 Comhairle report on dermatology services recommended the transfer of dermatology services from Hume Street to the St Vincent s Hospital site: The (1988) committee (supports), as a matter of principle, the concept that dermatology services in this country should be located at and be an integral part of a major general hospital providing a comprehensive range of specialties including pathology and anaesthesia It is recommended that the services at Hume Street Hospital should be physically transferred on to the St Vincent s Hospital site as soon as possible. Pending such transfer, there should be a joint management structure spanning St Vincent s Hospital and Hume Street Hospital. The ERHA has recently (January 2003) carried out a review of the dermatology services in the eastern region, including the role of Hume Street Hospital. The review states, inter alia, The ERHA supports the provision of specialist dermatology services on the site of an acute general hospital because of the comprehensive range of specialties provided. This should be augmented through the provision of primary dermatology services provided in a community setting. Due to historical developments, many patients are treated at Hume Street as inpatients This is not in keeping with current best practice as most dermatology services can be provided on an out-patient basis. It is hoped that the Hume Street service can be configured accordingly in consultation with major stakeholders and in keeping with best practice guidelines. The current committee fully endorses this objective which also has the support of the consultants and management of Hume Street Hospital. The committee recommends that the 1988 Comhairle recommendation, as outlined above, be implemented without further 15

21 delay. While the committee has been advised that there is scope to maintain a day-care dermatology service at Hume Street, inpatient services should no longer be provided there. Indeed, with the development of the dermatology services at St Vincent s University Hospital and in the health boards surrounding the ERHA which account for a significant volume of the existing workload in Hume Street, the need for and viability of any dermatology service at Hume Street is questionable. 4.3 DERMATOLOGY SERVICES FOR CHILDREN All consultant dermatologists in Ireland are trained to treat both adults and children. It is the advice of all of the dermatologists consulted with that this should continue to be the case. There are currently four consultant dermatologists who have sessional commitments to paediatric hospitals, two of whom have formal designations as consultant dermatologists with a special interest in paediatric dermatology. This designation has arisen from these posts being based at childrens hospitals. 4.4 DERMATOSURGERY Dermatosurgery covers the entire range of surgical activities related to the skin, ranging from diagnostic biopsies and dermatological oncology to cosmetic and aesthetic dermatology. Dermatological surgery, including micrographic surgery and laser therapy, is a component of the higher training scheme in dermatology. All consultant dermatologists do a limited amount of dermatosurgery, including biopsies and simple excisions with very basic flaps. 20 Dermatologists with an interest in surgery carry out procedures such as reconstruction, grafts and complicated flaps, as well as specialised treatments such as Mohs micrographic surgery*. There is no recognised post of Consultant Dermatologist with a formally designated special interest in dermatosurgery in Ireland. However, a number of the submissions to the committee from individual hospitals identified some existing consultants with expertise in this area. Comhairle is aware that St. James s Hospital has proposed the appointment of a consultant dermatologist with a designated special interest in dermatosurgery. Refer to section 6.5 of this report for details of recommendations regarding sub-specialisation. 4.5 DERMATOPATHOLOGY In Ireland, there is a small number of histopathologists with an interest in dermatopathology - a sub-specialty of histopathology. Dermatopathology is concerned with the study and diagnosis of diseases of the skin and the adjacent mucous membranes, cutaneous appendages and subcutaneous tissues by histological, histochemical, immunological, ultrastructural, molecular and other related techniques. Dermatopathologists are doctors who, after completing their training in either histopathology (Ireland, UK and parts of continental Europe 22 ) or dermatology (North America & parts of continental Europe), pursue additional training for the interpretation of skin biopsies. The accurate microscopic interpretation of the biopsy is important in the selection of appropriate therapies. Dermatopathology is an essential part of the specialist training programme in dermatology in Ireland. The committee advocates that each region should have a histopathologist with expertise in dermatopathology. * Named after Frederic E Mohs ( ), an American surgeon who, as a medical student, devised a system of microscopically controlled removal of skin tumours. It is an out patient procedure involving prior necrosis with zinc chloride paste, mapping of the tumour site and removal of a horizontal disc of tissue that is deemed to be the smallest amount that could possibly remove the tumour. The piece of tissue is then examined under the microscope (preferably by the dermatopathologist/histopathologist and the dermatologist) to look for evidence of tumour cells on the edges of the sample. If any is found, another thin layer of tissue is removed and examined. This procedure is repeated until no evidence of cancer can be detected. Mohs' surgery is particularly effective for difficult and recurrent skin cancers such as basal cell carcinomas and lentigo maligna as it allows for a high cure rate while sparing normal tissue. 20,21 16

22 4.6 WAITING LISTS Waiting lists for consultant dermatological services remain unacceptably high due, primarily, to the small number of consultant dermatologists in the public sector. Other factors include increased public awareness of treatments and heightened concern about skin cancer. 2 Data provided to the committee by hospital authorities relating to the number of patients on waiting lists and the waiting times for out-patient appointments (where available) are given at Appendix C. 17

23 5 PRINCIPLES FOR FUTURE DEVELOPMENT 5.1 EQUITABLE AND PATIENT-CENTRED SERVICE All patients, regardless of their geographic location should have equal access to dermatology services. The principles of equity, people-centredness, quality and accountability formed the foundations for the National Health Strategy Quality and Fairness, A Health System for You. 23 The Strategy sought to achieve fair access to healthcare, to ensure equitable access to services based on need. The Strategy stressed that services must be organised, located and accessed in a way that takes greater account of the needs and preferences of the community they serve. 5.2 NO CONSULTANT DERMATOLOGIST WORKING IN ISOLATION Each dermatology centre should be staffed by a minimum of two consultants. In addition, notwithstanding regional outreach commitments, each consultant dermatologist should have sessional commitments to a maximum of two hospitals. It is envisaged that with the appointment of more consultants, the configuration of the existing posts would be altered to reflect this. Details are given in section REGIONAL SELF-SUFFICIENCY A DERMATOLOGY SERVICE IN EACH REGION Each region should be self-sufficient in the provision of dermatology services, except in the case of highly specialised areas (e.g. complex dermatosurgery, the management of Epidermolysis Bullosa etc.). Each region should have its own regional dermatology centre, based in a major regional general hospital where the full range of clinical and laboratory services are provided The committee believes that self-sufficiency within each health board, as currently structured, is the way forward in the provision of dermatology care and that this is an achievable goal. This view is shared by the Irish Association of Dermatologists. The view of regionalisation expressed by Comhairle na nospidéal in its 1988 Dermatology Report was influenced by the advice of the Irish Association of Dermatologists and the prevailing economic circumstances at the time. Regional self-sufficiency is consistent with government policy outlined in the 1994 Health Strategy Shaping a Healthier Future A Strategy for effective healthcare in the 1990s 24 and echoed in the 2001 Health Strategy Dermatology is pre-dominantly an outpatient specialty. The committee reiterates the principles of the 1988 report that the major emphasis in the future development of dermatology services should be on out-patient clinics and day-care services rather than inpatient activity and that a network of peripheral clinics should be developed and maintained within each region to provide a local diagnostic and therapeutic service. The 18

24 small number of inpatients should be managed at the regional centre. The physical proximity of in-patient, out patient and day-care dermatology facilities would lead to a more integrated, and ultimately, a better dermatology service Facilities Each regional centre should incorporate all facilities and equipment necessary to provide a high quality dermatology service. From the consideration of available literature 25,26,27,28 and in consultation with consultant dermatologists in Ireland and Scotland, the committee suggests that the development of the facilities listed below would be appropriate in each regional dermatology centre. The committee has been advised that the capital investment required to ensure the provision of the facilities set out below is not excessive in the context of capital costs for developing some other specialties but the gain to patients and staff would be considerable. The committee suggests that each regional dermatology centre should be located on the site of a major acute hospital. We have been advised that the following resources are required: Core facilities: ü a dedicated outpatient dermatology department with a separate waiting area ü appropriate changing areas for patients ü appropriate areas for the application of topical treatments and dressings; appropriate bathing facilities for patients ü facilities for carrying out laser therapy and minor surgery, such as cryosurgery, curettage, simple excisions and biopsies, i.e. in a treatment room, under local anaesthetic. Larger and more complex surgical procedures should be done during dedicated theatre time ü equipment - including several phototherapy machines, including hand and foot phototherapy, equipment for photodynamic therapy and photosensitivity testing. ü Patch-testing facilities ü access to medical photography ü patient information and literature. Inpatient facilities: Comhairle na nospidéal - Report of the Committee on Dermatology Services - November 2003 There is a requirement for a small number of inpatient dermatology beds (preferably together) in each regional dermatology centre Patients with widespread chronic inflammatory skin diseases benefit from admission to hospital. 25 Patients requiring inpatient hospital care primarily with dermatology conditions are often admitted to various medical and/or surgical beds, sometimes resulting in suboptimal dermatological care. Each regional centre should incorporate an in-patient unit with dedicated in-patient beds. The Royal College of Physicians (London) 25,28 and the British Association of Dermatology recommend that; Two dedicated dermatological beds per 100,000 population are the minimum requirement, but eight beds are the minimum required to support appropriate staffing for a self-contained unit Dermatological beds in general medical wards are only satisfactory if there are appropriate facilities for bathing and treatment and patients receive care from specialist dermatology nurses. The committee has been advised that these recommendations from the UK would be a useful guide to service provision in Ireland. Dermatological beds within any one hospital should be located together, to facilitate optimal care of patients and specialised training of nurses and other staff. Provision should also be made for isolation and photoprotection. There are currently insufficient numbers of protected dermatology beds in Ireland. 19